TRICARE Changes to Nexium Coverage

5/1/2017

Starting on June 28, 2017, TRICARE will no longer include the drug Nexium in the preferred, or formulary, drug list, and it will no longer be available in military hospitals and clinics. In order to prepare for the change, patients are currently being asked to switch to one of the following three preferred alternatives that have been shown to demonstrate effective results.

  • Omeprazole
  • Pantoprazole
  • Rabeprazole

Your doctor may determine that the preferred alternatives are not right for you and that Nexium is medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition.. In those cases, TRICARE will continue to cover the cost of Nexium, minus the $20 copay for a 90-day supply of home delivery and $24 copay for a 30-day supply via a retail outlet. On or after June 28, 2017, your doctor must submit a prior authorization and a reason why Nexium is medically necessary via the Express Scripts doctor line for you to fill your prescription. For patients who continue to use Nexium with a prior authorization but WITHOUT a doctor’s medical necessity determination, the non-formulary copay cost will be $49 for a 90-day supply via home pharmacy delivery or $50 for a 30-day supply via a retail outlet.

What is GERD and how is it treated?

Nexium is a popular drug to treat gastroesophageal reflux disease (GERD). GERD is a chronic digestive disease, which occurs when stomach acid flows back into the esophagus (or food pipe). This acid irritates the lining of the esophagus which over time can lead to GERD. Many people can make lifestyle changes and take over-the-counter medication to manage their GERD symptoms. Other people need stronger medicine to reduce symptoms. Proton pump inhibitors (PPI) is the drug class used to treat GERD. PPIs decrease the amount of acid created in the stomach and relieve GERD symptoms. The drugs also work to heal previous acid damage to the stomach and esophagus.

The Military Health System is committed to supporting the health and well-being of all beneficiaries. For more information regarding the PPI alternatives please visit the National Institutes of Health’s MedlinePlus website. For more information regarding brand, generic drugs and which drugs are on TRICARE’s formulary list please visit the TRICARE website

Last Updated 10/26/2017